Download RPT 244 Critical Care Considerations for the RCP

11/13/2012
RPT 244
CRITICAL CARE CONSIDERATIONS FOR THE RCP
Plan of Instruction
Effective Date: Spring Semester 2013
Version Number: 2012-1
COURSE DESCRIPTION:
This course provides for continued discussion concerning the monitoring and
maintenance of patients who are treated in the critical care area of an acute care
hospital. Course emphasis is placed upon advanced monitoring and assessment
techniques employed in the treatment of the critical care patient. Upon completion, the
student should be able to demonstrate increased psychomotor and cognitive abilities as
pertaining to critical care. CORE
CREDIT HOURS
Theory
Lab
Total Credit
1 hour
1 hour
2 hours
NOTE: Theory credit hours are a 1:1 contact to credit ratio. Colleges may schedule lab hours as 3:1 and/or
2:1 contact to credit ratio. Clinical hours are 3:1 contact to credit ratio. (Ref Board Policy 705.01)
Alabama Community College System
Copyright© 2011
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Critical Care Considerations for the RCP
RPT 244
PREREQUISITE COURSES
As determined by college.
CO-REQUISITE COURSES
As determined by college.
INSTRUCTOR NOTE: This course serves as a review of previously taught material in
RPT 213, 222, 223, 232, 233, and 234. It is intended to enhance critical thinking skills
and helps to prepare students for their credentialing exams.
PROFESSIONAL COMPETENCIES
 Explain the anatomy and physiology of the cardiopulmonary system.
 Describe how to properly insert, maintain, and troubleshoot artificial airways.
 Comprehend the foundational principles of the electrophysiology of the heart and
electrocardiography.
 Comprehend the foundational principles and enhanced assessment techniques
related to hemodynamic monitoring.
 Describe the monitoring techniques and management strategies used during
noninvasive and invasive ventilation to improve oxygenation and ventilation
status.
 Comprehend the enhanced skills of blood gas classification and electrolyte
disturbances.
INSTRUCTIONAL GOALS
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Cognitive – Comprehend principles and concepts related to the cardiopulmonary
and renal systems as it relates to respiratory care.
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Psychomotor – Apply principles of the assessment techniques, monitoring
techniques, and therapeutic interventions of the cardiopulmonary and renal
systems as related to respiratory care.
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Affective – Value the importance of recall, application, and analysis of the
principles of the cardiopulmonary and renal systems at it relates to respiratory
care.
STUDENT OBJECTIVES
Condition Statement: Unless otherwise indicated, evaluation of student’s attainment
of objectives is based on knowledge gained from this course. Specifications may be in
the form of, but not limited to, cognitive skills diagnostic instruments, manufacturer’s
specifications, technical orders, regulations, national and state codes, certification
agencies, locally developed lab/clinical assignments, or any combination of
specifications.
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STUDENT LEARNING OUTCOMES
MODULE A – ANATOMY AND PHYSIOLOGY OF THE CARDIOPULMONARY SYSTEM
MODULE DESCRIPTION – The purpose of this module is to teach the students the
anatomy and physiology of the respiratory system. Topics include anatomy and
physiology of the respiratory system, ventilation, diffusion of pulmonary gases, and
pulmonary functions measures.
PROFESSIONAL COMPETENCIES
PERFORMANCE OBJECTIVES
KSA
A1.0 Explain the anatomy and
A1.1 This module is measured
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physiology of the
cognitively.
cardiopulmonary system.
LEARNING OBJECTIVES
A1.1.1 Identify and explain the structure of the upper and lower airways.
A1.1.2 Explain the functions of ventilation as related to the human body.
A1.1.3 Explain the principles and dynamics of alveolar capillary diffusion.
A1.1.4 Identify and explain lung volumes and capacities.
A1.1.5 Explain how pulmonary mechanics are measured.
MODULE A OUTLINE:
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Upper Airway
 Nose
 Oral Cavity
 Pharynx
 Functions of the Upper Airway
Nose
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Functions Of The Nose
Nasal Septum
Nares- or Nostrils - Openings into the Nose
Vestibules
Nasal Cavity
Cilia
Turbinates or Conchae
o Superior
o Middle
o Inferior
Paranasal Sinuses
o Maxillary
o Frontal
o Ethmoid
o Sphenoid
Oral Cavity
o Vestibule
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o Hard Palate and Soft
Pharynx
o Nasopharynx
o Oropharynx
o Laryngopharynx
Lower Airway
 Larynx
o Functions of the Larynx
 Passageway For Air Between The Pharynx & Trachea
 Works As A Protective Mechanism Against Aspiration
 Generates Sound For Speech (Phonation)
 Aids In The Cough Process With Epiglottic Closure
 Cartilages of the Larynx
o Singles
 Thyroid
 Cricoid
 Epiglottis
o Pairs
 Arytenoid
 Corniculate
 Cuneiform
 Interior of the Larynx
 True Vocal Cords
 False Vocal Cords
 Glottis
 Hyoid Bone
 Ventilatory Function of the Larynx
Tracheobronchial Tree
 Forms of Branching Airways
o Cartilaginous Airways (Conducting Zone)
 Trachea
 Main Stem Bronchi
 Lobar Bronchi
 Segmental Bronchi
 Sub Segmental Bronchi
o Non - Cartilaginous Airways (Also Conducting Zone)
 A- Bronchioles
 B- Terminal Bronchioles
o Sites of Gas Exchange (Respiratory Zone)
 A- Respiratory Bronchioles
 B- Alveolar Ducts
 C- Alveolar Sacs
 Trachea
 Carina
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Mainstem Bronchi
Lobar Bronchi
Segmental Bronchi
Sub Segmental Bronchi
Bronchioles
Terminal Bronchioles
Site of Gas Exchange
 Respiratory Bronchioles
 Alveolar Duct
 Alveolar Sacs
 Canals of Lambert
 Alveolar Epithelium
Alveoli
 Type I Cells (Major Sites of Alveolar Gas Exchange)
 Type II Cells Primary Source of Pulmonary Surfactant
 Surfactant
 Pores Of Kohn
 Alveolar Macrophages
o Type III Cells
 Interstituim
Mucus
 Goblet Cells
 Submucosal or Bronchial Glands
 Two Layers of Mucus
o Gel Layer (More Viscous Layer)
o Sol Layer
Bronchial Blood Supply
 Bronchial Arteries
 Bronchial Veins
Pulmonary Vascular System
 The PVS is Composed of:
o Arteries
o Arterioles
o Capillaries
o Venules
o Veins
The Lymphatic System
 Lymphatic Vessels
 Lymph Nodes
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Juxta - Alveolar Lymphatics
Neural Control of the Lungs
Autonomic Nervous System
 Regulates Involuntary Vital Functions:
o Activity of the Cardiac Muscle
o Activity of the Smooth Muscle
o Activity of the Glands
 Two Divisions of the Autonomic Nervous System:
o Sympathetic
o Parasympathetic
Lungs
 Composition
o Apex
o Mediastinal Border
o Hilum
o Base
Right Lung
 Lobe and Segments
o Upper Lobe
o Apical, Posterior, Anterior
o Middle Lobe
o Lateral, Medial
o Lower Lobe
o Superior, Medial Basal, Anterior Basal, Lateral Basal, Posterior Basal
Left Lung
 Lobe and Segments
o Upper Lobe (Upper Divsion)
o Apical / Posterior, Anterior
o Upper Lobe (Lower Division) (Lingular)
o Superior Lingula Inferior Lingula
o Lower Lobe
o Superior, Anterior Medial, Lateral Basal, Posterior Basal
Mediastinum
 Heart
 Trachea
 Major Blood Vessels
 Nerves
 Esophagus
 Thymus Gland
 Lymph Modes
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Pleural Membranes
 Visceral Pleurae
 Parietal Pleurae
Thorax
 Sternum
o Manubrium
o Body
o Xyphoid Process
 Ribs
o 7 True Ribs
o 8,9 & 10 False Ribs Do Not Connect To The Sternum
o 11 & 12 Floating Ribs Do Not Connect To Anything
 Intercostal Space
Muscles of Ventilation
 Diaphragm
o Right Hemidiaphragm
o Left Hemidiaphragm
 Accessory Muscles of Inspiration
o Scalene Muscles - Elevate the 1 & 2 Ribs
o Sternocleidomastoid - Elevates the Sternum
o Pectoralis Major - Elevates the Chest
o Trapezius Muscles - Elevates the Thoracic Cage
o External Intercostal Muscles - Pulls Ribs In and Out
 Accessory Muscles Of Expiration
o Rectus Abdominus
o External Abdominus Oblique
o Internal Abdominus Oblique
o Transversus Abdominus
o Internal Intercostal
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MODULE B – CLINICAL APPLICATIONS OF AIRWAY MANAGEMENT
MODULE DESCRIPTION – This module discusses primary indications for an artificial
airway, and proper management. Topics include airway clearance techniques, methods
to ensure airway patency, and special procedures related to airway management.
PROFESSIONAL COMPETENCIES
PERFORMANCE OBJECTIVES
KSA
B1.0 Describe how to properly
B1.1 This module is measured
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insert, maintain, and
cognitively, and through computer
troubleshoot artificial airways.
software and/or mannequin
simulation.
B1.2 Select and insert the appropriate
artificial airway for the patient
based on clinical presentation.
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B1.2 Assess and suggest/modify
therapy based on clinical
assessment.
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LEARNING OBJECTIVES
KSA
B1.1.1 Identify the need for and select the appropriate artificial airway.
B1.1.2 Describe how to maintain and troubleshoot artificial airways.
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B1.2.1 Demonstrate proper insertion, maintenance, and assessment of an
artificial airway.
MODULE B OUTLINE:
A. Establishing an artificial airway
 Clinical practice guideline
 Routes
o Pharyngeal airways
 Nasopharyngeal airway
 Oropharyngeal airway
 Tracheal airway
o Airway Tubes
 Endotracheal tubes
 Tracheostomy tubes
o Procedures
 Orotracheal intubation
 Nasotracheal intubation
 Direct visualization
 Blind passage
 Tracheostomy
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B. Alternative airway devices
 Laryngeal mask airway
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Double-lumen airway
Surgical emergency airways
o Cricothyroidotomy
o Percutaneous transtracheal ventilation
C. Airway complications and trauma associated with artificial airways
 Laryngeal lesions
o Stenosis
 Tracheal lesions
o Tracheomalacia
o Tracheal stenosis
o Tracheoesophageal fistula
o Tracheoinnominate artery fistula
 Prevention of trauma
D. Aspects of airway maintenance
 Securing the airway and confirming placement
 Providing for patient communication
 Ensuring adequate humidification
 Minimizing the possibility of infection
 Aiding in secretion clearance
o Suctioning
 Endotracheal
 Clinical practice guideline
 Equipment and procedure
 Minimizing complications
 Adverse responses
 Nasotracheal
 Clinical practice guideline
 Equipment and procedure
 Minimizing complications
 Adverse responses
 Sputum sampling
 Providing appropriate cuff care
o Importance of cuff pressure
 Measuring
 Adjusting
 Minimizing aspiration
 Alternative cuff designs
o Care of tracheostomy and tube
 Trach care
 Changing a tracheostomy tube
 Troubleshooting airway-related problems
o Tube obstruction
o Cuff leaks
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o Accidental extubation
E. Extubation & Decannulation
 Assessing patient readiness for extubation
o Clinical practice guideline
 Procedures
o Orotracheal or Nasotracheal tubes
o Tracheostomy tube removal
 Fenestrated tracheostomy tubes
 Progressively smaller tubes
 Tracheostomy buttons
 Assessment after tracheostomy decannulation
F. Bronchoscopy
 Rigid tube bronchoscopy
 Flexible fiberoptic bronchoscopy
o Procedure
 Premedication
 Equipment preparation
 Airway preparation
 Monitoring
 Assisting with the procedure
 Recovery
 Complications
MODULE C – ELECTROPHYSIOLOGY OF THE HEART AND
ELECTROCARDIOGRAPHY
MODULE DESCRIPTION – The purpose of this module is to teach the foundational
principles relating to the electrophysiology of the heart and electrocardiography. Topics
include the major components of the properties of the cardiac muscle, the conductive
system of the heart, the 12-lead ECG system, and ECG interpretation.
PROFESSIONAL COMPETENCIES
PERFORMANCE OBJECTIVES
KSA
C1.0 Comprehend the foundational
C1.1 This module is measured through
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principles of the
properly performing an ECG,
electrophysiology of the heart
interpreting the rhythms, and
and electrocardiography.
determining appropriate
treatment.
Note: This assessment is performed
through computer software and/or
mannequin simulation.
LEARNING OBJECTIVES
C1.1.1 Describe the electrophysiology of the heart.
C1.1.2 Describe the properties of the cardiac muscle.
C1.1.3 Identify the major components of the conductive system of the heart.
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C1.1.4 Describe the components of the standard 12-lead ECG system.
C1.1.5 Describe the normal electrocardiogram (ECG) configurations and their
expected measurements.
C1.1.6 Describe the systematic approach to ECG interpretation.
C1.1.7 Discuss appropriate 12-lead ECG placement.
C1.1.8 Identify the treatment options for abnormal arrhythmias.
MODULE C OUTLINE:
 Electrophysiology of the heart
o Action potential
 Phase 0
 Phase 1
 Phase 2
 Phase 3
 Phase 4
 Properties of the cardiac muscle
o Automaticity
o Excitability
o Conductivity
o Contractility
 Major components of the conductive system of the heart
o Sinoatrial node
o Atroventricular junction
o Bundle of His
o Right and left bundle branches
o Purkinjie fibers
 Cardiac effects of the
o Sympathetic nervous system
o Parasympathetic nervous system
 Components of the standard limb leads
o Bipolar limb leads
 Lead I
 Lead II
 Lead III
o Unipolar leads
 aVR
 aVL
 aVF
o Axes
o Einthoven’s triangle
 Components of the precordial (chest) leads
o V1
o V2
o V3
o V4
o V5
o V6
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Normal ECG configurations and their expected measurements
o The components of the ECG paper
o P wave
o PR interval
o QRS complex
o ST segment
o T wave
o U wave
o QT interval
Systematic approach to ECG interpretation
o General inspection
o Analysis of ventricular activity
o Analysis of atrial activity
o Assessment of atrioventricular relationship
Describe the P wave, PR interval, QRS complex, QRS rate, and QRS rhythm in the
following rhythms in order to identify them
o Normal sinus rhythm
o Sinus bradycardia
o Sinus tachycardia
o Sinus arrhythmia
o Sinus block
o Sinus arrest
o Premature atrial complex
o Atrial bigeminy
o Atrial tachycardia
o Atrial flutter
o Atrial fibrillation
o Uniform PVCs
o Multiform PVCs
o Bigeminal PVCs
o Trigeminal PVCs
o Ventricular tachycardia
o Ventricular flutter
o Ventricular fibrillation
o 1st Degree AV heart block
o 2nd Degree AV heart block
o 3rd Degree AV heart block
o Asystole
Treatment options for abnormal arrhythmias
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MODULE D – HEMODYNAMIC MONITORING
MODULE DESCRIPTION – The purpose of this module is to teach the foundational
principles relating to the indications, contraindications, hazards/complications, and
monitoring techniques used during hemodynamic monitoring. Topics include monitoring
equipment, pressure and waveform monitoring, troubleshooting techniques, and
interpretation of hemodynamic values.
PROFESSIONAL COMPETENCIES
PERFORMANCE OBJECTIVES
KSA
D1.0 Comprehend the foundational
D1.1 This module is measured
3
principles and advanced
cognitively.
assessment techniques related
to hemodynamic monitoring.
LEARNING OBJECTIVES
D1.1.1 Explain the functions and components of the cardiovascular system,
including the importance of monitoring how blood flows through the heart,
heart sounds, blood pressure and blood volume, and stroke volume.
D1.1.2 Explain the factors that regulate and determine cardiac output, including
the importance or monitoring ejection fraction and cardiac index.
D1.1.3 Describe the types of monitoring equipment used in hemodynamic
monitoring and its assembly.
D1.1.4 Describe the indications, contraindications, methods used, hazards,
troubleshooting techniques, waveform displays, and normal vs. abnormal
values obtained during arterial pressure monitoring.
D1.1.5 Describe the indications, contraindications, methods used, hazards,
troubleshooting techniques, waveform displays, and normal vs. abnormal
values obtained during central venous pressure monitoring.
D1.1.6 Describe the indications, contraindications, methods used, hazards,
troubleshooting techniques, waveform displays, and normal vs. abnormal
values obtained during pulmonary artery pressure monitoring.
D1.1.7 Identify the definition, normal ranges, equations, and clinical significance
of stroke index, oxygen delivery, oxygen consumption, oxygen extraction
ratio assessed during hemodynamic monitoring.
D1.1.8 Describe the clinical manifestations of various cardiopulmonary
conditions and identify the hemodynamic values associated with each.
MODULE D OUTLINE:
 Functions and Components of the Cardiovascular System
o Gross anatomy of the heart
 Point of maximum impulse
 Heart sounds
 Heart murmurs
 Heart disturbances
 Tricuspid valve deficiencies
 Pulmonic valve deficiencies
 Bicuspid (mitral) valve deficiencies
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 Aortic valve deficiencies
 Right vs. left ventricular hypertrophy
o Blood flow through the heart
 Heart
 Four chambers
 Arteries
 Capillaries
 Capillary beds
 Veins
o Blood pressure
 Systemic vs. pulmonary circulation pressures
o Blood volume
 Cardiac output
 Systemic vascular resistance (SVR)
o Stroke Volume
 Normal range
 Preload
 Afterload
 State of contractility
Factors that Regulate and Determine Cardiac Output
o Definition
o Normal range
o Heart rate
o Stroke volume
 Definition
 Equation
 End-diastolic volume (EDV)
 End-systolic volume (ESV)
o Venous return
o Preload
 Definition
 Starling’s Law
 Right ventricular preload (CVP or right atrial pressure)
 Left ventricular preload (PAWP or left atrial pressure)
 Factors that influence preload
 Circulating blood volume
 Distribution of volume
 Atrial contraction
 Ventricular contraction
 Agents used to increase preload (volume expanders)
 Crystalloid solutions
 Colloid solutions
 Agents used to reduce preload
 Diuretic agents
 Vasodilators (venodilators)
o Afterload
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Definition
Vascular resistance
 PVR
 SVR
 Agents used to increase afterload
 Alpha receptor stimulators
 Agents used to decrease afterload
 Vascular smooth muscle relaxants
 Calcium channel blocking agents
 Alpha receptor inhibitors
 Angiotension converting enzyme inhibitors (ACE)
o Contractility
 Positive inotropic agents
 Beta-receptor stimulators
 Phosphodiesterase inhibitors
 Cardiac glycosides
 Negative inotropic agents
 Beta receptor inhibitors (Beta blocking agents)
 Calcium channel blocking agents
Ejection Fraction
o Definition
o Normal range
o Conditions/Factors that increase or decrease ejection fraction
o Equation
Cardiac Index (CI)
o Definition
o Normal range
o Conditions/Factors that increase or decrease cardiac index
o Equation
Equipment Used for Hemodynamic Monitoring
o Fluid system attached to a water manometer
 Drawbacks
o Fiberoptic monitoring systems
 Maintenance
 Cost
o Fluid system with transducer/amplifier/monitor components
 Purpose of
 Pressure transducer
 Amplifier
 Monitor
o Oscilloscope and strip chart recorder
o Ringing
o Dynamic response
o Fidelity
o Natural frequency
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 Flush solution
 Flush device
 Dynamic response testing (square wave testing)
 Quality Assurance
 Artifacts
 Catheter whip
 Damping
o Optimally damped
o Underdamped
o Overdamped
 Overshoot/undershoot
 Catheter and low-compliance extension tubing
o Assembly of monitoring system
 Patient positioning and special considerations
 Severe CHF and acute respiratory failure patients
 Eliminating the effects of hydrostatic pressure
 Leveling a pressure transducer
 Procedure for zero referencing
 Monitor and transducer calibration
 Troubleshooting pressure monitoring systems
Arterial Pressure Monitoring
o Definition
o Normal range
o Conditions/Factors that increase or decrease arterial blood pressure
o Indirect vs. direct method
 Indirect method
 Indications
 Contraindications
 Hazards
 Blood pressure cuff technique
 Direct method
 Indications
 Contraindications
 Hazards and complications (Troubleshooting and Prevention)
o Air bubbles
o Loose tubing connections
o Transducer and catheter placement
 Too high vs. too low
o Inadequate heparin solution bag pressure
o Blood clots at catheter tip (or in tubing)
o Catheter tip blocked by wall of artery
o Hematomas
o Absent pulse distal to puncture site
o Bleedback into tubing, dome, or transducer
o Hemorrhage
o Infection
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o Sepsis
 Arterial cannulation sites
 Arterial catheter insertion technique
 Care of arterial catheters
 Obtaining blood samples from arterial catheters
 Removal of arterial catheters technique
o Mean arterial pressure (MAP)
 Definition
 Normal range
 Conditions/Factors that increase or decrease MAP
 Equation
o Pulse pressure
 Definition
 Normal range
 Conditions/Factors that increase or decrease pulse pressure
 Equation
o Arterial pressure waveforms
 Phase I
 Dicrotic notch
 Phase II
 Systolic overshoots
 Conditions that affect waveform morphology
 Arrhythmias
 Hypertension
 Hypotension
 Aging
 Hypovolemia
 Vasoconstriction
o Systemic vascular resistance (SVR)
 Definition
 Normal range
 Conditions/Factors that increase or decrease SVR
 Equation
 Units vs. dynes/sec/cm-5
 Medications used to
 Increase SVR
o Alpha receptor stimulators
 Decrease SVR
o Vascular smooth muscle relaxants
o Calcium channel blocking agents
o Alpha receptor inhibitors
o Angiotension converting enzyme (ACE) inhibitors
Central Venous Pressure (CVP) Monitoring
o Definition
o Indications
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 Right atrial pressure
 right ventricular end-diastolic pressure
 Intravascular volume status
o Contraindications
o Hazards and complications (Troubleshooting and Prevention)
 Hemorrhage
 Vascular erosion
 Arrhythmia
 Local and systemic infection
 Fluid overload (hypervolemia)
 Hypothermia
 Thromboembolic problems
 Electrical microshocks
 Air emboli
 Perforation of the cardiac chambers
 Pneumothorax
o Protocols for obtaining CVP measurements
 Calibrated water manometer vs. pressure transducer system
o Normal range
 mm Hg vs. cm H2O (conversion equations)
o Conditions/Factors that increase or decrease CVP
 Mechanical ventilator-induced factors
o CVP catheter components, insertion sites, and technique
 Central venous access
 Subclavian vein
 Internal jugular vein
 Femoral vein
 Peripheral venous access
 External jugular vein
 Antecubital sites (cephalic or basilic sites)
o Central Venous Pressure Waveforms
 “a”, “c”, “v”, “x” and “y” descent
Pulmonary Artery Pressure (PAP) Monitoring
o Definition
o Indications
 Cardiac output (CO/QT)
 Definition
 Normal range
 Conditions/Factors that increase or decrease cardiac output
 Invasive methods used to calculate cardiac output
o Fick equation (Fick oxygen consumption method)
o Dye dilution technique
o Thermodilution method
 Noninvasive methods used to calculate cardiac output
o Doppler ultrasonography
o Thoracic electrical bioimpedance cardiography
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CVP (RAP and RVP)
PAP
 Normal range (systolic and diastolic)
 Conditions/Factors that increase or decrease PAP
 PCWP/PWP
 Definition
 Normal range
 Measurement
 Conditions/Factors that increase or decrease PCWP/PWP
 PvO2
 Definition
 Normal range
 Measurement
 Conditions/Factors that increase or decrease PvO2
 SvO2
 Definition
 Normal range
 Equation
 Conditions/Factors that increase or decrease SvO2
 CvO2
 Definition
 Normal range
 Equation
 Conditions/Factors that increase or decrease CvO2
 CaO2-CvO2
 Definition
 Normal range
 Significance of an increased or decreased CaO2-CvO2
o Contraindications
o PAP catheter components, insertion sites, and technique
 4-Lumen Swan Ganz Catheter
 Distal lumen
 Balloon inflation port
 Proximal right arterial port
 Thermistor port
o Cardiac output measurement
 Proximal port
 Central venous access
 Subclavian vein
 Internal jugular vein
 Femoral vein
 Peripheral venous access
 External jugular vein
 Antecubital sites (cephalic or basilic sites)
 Cutdown technique
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Critical Care Considerations for the RCP

RPT 244
 Purcutaneous approach
 Percutaneous approach using the Seldinger technique
o Pulmonary artery pressure waveforms
 Systolic vs. diastolic pressures
 Dicrotic notch
o Hazards and complications (Troubleshooting and Prevention)
 Ventricular arrhythmias
 Pneumothorax, hydrothorax
 Air embolism
 Damage to veins, arteries, nerves
 Perforation of the heart or pulmonary artery
 Infection
 Thrombophlebitis
o Mean pulmonary artery pressure (MPAP)
 Definition
 Normal range
 Conditions/Factors that increase or decrease MPAP
 Equation
o Evaluation of Pad-PWP gradient
 Increases vs. decreases in gradient
o Pulmonary vascular resistance (PVR)
 Definition
 Normal range
 Conditions/Factors that increase or decrease PVR
 Equation
 Units vs. dynes/sec/cm-5
Additional Hemodynamic Values
o Stroke index (SI)
 Definition
 Normal range
 Conditions/Factors that increase or decrease stroke index
 Equation
o Oxygen delivery (DO2)
 Definition
 Normal range
 Conditions/Factors that increase or decrease oxygen delivery
 Equation
o Oxygen consumption (VO2)
 Definition
 Normal range
 Conditions/Factors that increase or decrease oxygen consumption
 Equation
o Oxygen extraction ratio
 Definition
 Normal range
 Conditions/Factors that increase or decrease PVR
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Critical Care Considerations for the RCP

RPT 244
 Equation
Hemodynamic Profiles
o Hypervolemia
o Hypovolemia
o Hypovolemic Shock
o Left Ventricular Failure
o Right Ventricular Failure
o Pulmonary Embolism
o Pulmonary Hypertension
o Septic Shock
o Anaphylactic Shock
o Cardiogenic Shock
o Acute Cardiac Tamponade
o ARDS (Noncardiogenic PE)
o COPD
o Acute Myocardial Infarction
o CHF/Pulmonary Edema/RHF
MODULE E – VENTILATOR MONITORING MANAGEMENT STRATEGIES
MODULE DESCRIPTION – The purpose of this module is to teach the students various
methods to monitor and improve ventilation and oxygenation based on the patient’s
cardiopulmonary status. Topics include ventilator graphics, hemodynamic monitoring,
correcting ABG abnormalities, PEEP studies, recruitment maneuvers and pharmacological
agents.
PROFESSIONAL COMPETENCIES
E1.0 Describe the monitoring
techniques and management
strategies used during
noninvasive and invasive
ventilation to improve
oxygenation and ventilation
status.
PERFORMANCE OBJECTIVES
E1.1
This module is measured
cognitively, and through computer
software and/or mannequin
simulation.
LEARNING OBJECTIVES
E1.1.1 Discuss initial assessment findings of the mechanically ventilated patient.
E1.1.2 Describe the applications and relationships of ventilator graphics.
E1.1.3 Discuss the monitoring techniques of noninvasive and invasive
ventilation.
E1.1.4 Discuss the clinical use of hemodynamic monitoring of a mechanically
ventilated patient.
E1.1.5 Explain various considerations before making ventilator adjustments to
reduce work of breathing and improve ventilation based on patient
diagnosis, arterial blood gas results, and ventilator parameters.
E1.1.6 Discuss the theories of proning and the effects on ventilation-perfusion
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KSA
3
KSA
4
3
4
3
4
3
21
Critical Care Considerations for the RCP
RPT 244
and optimum PEEP level studies.
E1.1.7 Identify the pharmacological interventions and their therapeutic effects on
the critically ill patient.
MODULE E OUTLINE:
 General Patient Assessment
 Chest inspection and auscultation
 Mechanical ventilators
o Clinical application of modes
o Output wave forms
 Physiology of ventilatory support
o Pressure and pressure gradients
o Effects of mechanical ventilation on oxygenation
 Pulse Oximetry
 Arterial Blood Gases
 Transcutaneous Blood Gas Monitoring
o Effects of mechanical ventilation on ventilation
 Arterial Blood Gases
 Capnography
 Transcutaneous Blood Gas Monitoring
o Effects of positive pressure mechanical ventilation on lung mechanics
o Minimizing adverse pulmonary effects
o Physiologic effects of ventilator modes
o Cardiovascular effects of mechanical ventilation
 Minimizing the cardiovascular effects of mechanical ventilation
o Other body system effects of mechanical ventilation
o Complications of mechanical ventilation
 Fluid Balance and Anion Gap
 Ventilator Management Strategies
o Inverse ratio ventilation
o Prone ventilation-perfusion
o Obtaining optimum PEEP with ARDS
 Recruitment-derecruitment maneuver
 Deflection point
o Pharmacological Interventions
 Sedatives
 Indications
 Contraindications
 Potential side effects
 Analgesics
 Indications
 Contraindications
 Potential side effects
 Neuromuscular blocking agents
 Indications
 Contraindications
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4
22
Critical Care Considerations for the RCP

RPT 244
Potential side effects
MODULE F – BLOOD GAS CLASSIFICATION
MODULE DESCRIPTION – The purpose of this module is to teach the students the
enhanced skills of blood gas classification. Topics include acid-base status, acid-base
disturbances, oxygenation status, compensation assessment, complete blood gas
classification, electrolyte disturbances, hypoxemia, shunting, and hypoxia.
PROFESSIONAL COMPETENCIES
PERFORMANCE OBJECTIVES
KSA
F1.0 Comprehend the enhanced
F1.1 This module is measured
4
skills of blood gas classification
cognitively and through computer
and electrolyte disturbances.
software simulation.
LEARNING OBJECTIVES
F1.1.1
F1.1.2
F1.1.3
F1.1.4
F1.1.5
F1.1.6
Describe acid-base status as it relates to pH assessment.
Identify the four primary acid-base disturbances.
Explain how to determine compensation assessment.
Identify oxygenation status and explain PaO2 classification.
Explain how to determine complete blood gas classification.
Explain how ventilation and kidney function regulate body fluids,
electrolytes, and acid-base disturbances.
F1.1.7 Explain how to assess a patient with hypoxemia and shunting.
F1.1.8 Explain how to treat a patient with hypoxemia and shunting.
F1.1.9 Explain how to assess and treat a patient with hypoxia.
MODULE F OUTLINE:
 Acid-base status
o pH assessment
o Clinical significance of pH
o Clinical manifestations of abnormal pH
o Classification of pH
 Primary acid-base disturbances
o Respiratory acid-base status
 PaCO2 classification
 Inverse relationship (PaCO2-pH)
o Metabolic acid-base status
 HCO3 classification
 Direct relationship (HCO3-pH)
o Base excess [BE] assessment
 Compensation assessment
o Uncompensated acid-base disturbance
o Partially compensated acid-base disturbance
o Completely compensated acid-base disturbance
 Oxygenation status
o PaO2 classification
 Normoxemia
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KSA
4
4
4
4
4
4
4
4
4
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Critical Care Considerations for the RCP
RPT 244








Hyperoxemia
Hypoxemia
 Mild
 Moderate
 Severe
 Efficiency of Oxygen Uptake
 Normal FIO2 relationship
 PaO2/FIO2 (Oxygenation Ratio)
Complete blood gas classification
Body fluids and electrolytes
o Fluid compartments
o Electrolytes
 Electrolyte distribution
 Plasma electrolytes
o Major plasma cations
 Sodium
 Potassium
 Calcium
 Magnesium
Sodium regulation in the kidneys
o Chemical mechanisms
 NaCl mechanism
 NaHCO3 mechanism
o Renin-angiotensin system
o Total sodium reabsorption
o Regulation of [HCO3]
o Diuretics
 Interference with NaCl reabsorbtion
 Interference with NaHCO3 reabsorption
o Hyperaldosteronism
 Secondary hyperaldosteronism
 Primary hyperaldosteronism
Assessment of Hypoxemia
Effects of cardiac output on PaO2
o Changes in cardiac output or shunting
 Decreased cardiac output with a normal shunt
 Increased shunting with normal cardiac output
 Decreased cardiac output with an increased shunt
 Increased cardiac output with an increased shunt
o Mechanism of decreased PvO2
Assessment of physiologic shunting
o Indices of physiologic shunting
 Classic shunt equation
 Estimated shunt equations
 P(A-a)O2
 PaO2/PAO2
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24
Critical Care Considerations for the RCP




RPT 244
 PaO2/FIO2
Differential diagnosis of hypoxemia
o Hypoventilation
 Hypoventilation with increased shunting
 Hypoventilation, secondary to hemodialysis
o Absolute shunting
 Capillary shunting
 Anatomic shunting
 The 100% O2 test
o Relative shunting
o Diffusion defects
o Effects of altitude and air travel in hypoxemia
Clinical appearance of the patient with hypoxemia/hypercapnia
Treating acute hypoxemia
o Oxygen therapy
 High-flow systems
 Low-flow systems
 Excessive oxygen therapy
 High FIO2 levels
 High PaO2 levels
o Mechanical ventilation
 Acute lung injury/acute respiratory distress syndrome
 Acute respiratory distress syndrome/ARDS Net
 Open lung approach
 Permissive hypercapnia
 PaO2 targets and permissive hypercapnia
o Positive end-expiratory pressure (PEEP)
 Definition and waveforms
 Indications
 Mechanism of effectiveness
 Complications
 Decreased cardiac output
 Decreased renal function/urine output
 Decreased venous return
 Pulmonary barotrauma
 Deterioration of ventilation-perfusion ratio
 Increased intracranial pressure (ICP) and decreased cerebral
perfusion pressure (CPP)
o Nitric oxide
o Long-term oxygen therapy
Assessment and treatment of hypoxia
o Arterial oxygen variables
 PaO2
 SaO2
o Blood hemoglobin concentration
 Anemia
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Critical Care Considerations for the RCP

RPT 244
 Laboratory diagnosis of anemia
 Types of anemia
 Anemia and hypoxia
 Blood transfusions
o Circulatory status
 Cardiac output
 Shock
o Hemodynamic monitoring
o Key indicators of hypoxia
 Lactate
 Mixed venous oxygenation indices
 Mixed venous oxygen saturation
 Mixed venous oxygen partial pressure
Oxygen uptake and utilization
LEARNING OUTCOMES TABLE OF SPECIFICATIONS
The table below identifies the percentage of learning objectives for each module.
Instructors should develop sufficient numbers of test items at the appropriate
level of evaluation.
Limited
Knowledge and
Proficiency
KSA
Module A
Module B
Module C
Module D
Module E
Module F
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1
Moderate
Knowledge
and
Proficiency
2
50%
Advanced
Knowledge
and
Proficiency
3
40%
67%
25%
100%
42%
Superior
Knowledge
and
Proficiency
4
60%
33%
25%
58%
100%
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Critical Care Considerations for the RCP
RPT 244
The KSA is NOT determined by the verb used in the learning objective, but rather in the context in which
the verb is used and the depth of knowledge and skills required.
Example: Three KSA levels using the same verb (describe):
KSA 1 – Describe three characteristics of metamorphic rocks. (simple recall)
KSA 2 – Describe the difference between metamorphic and igneous rocks. (requires cognitive
processing to determine the differences in the two rock types)
KSA 3 – Describe a model that you might use to represent the relationships that exist within the rock
cycle. (requires deep understanding of rock cycle and a determination of how best to represent it)
Indicator
Learner’s Knowledge, Skills and Abilities
Key Terms
Description
1
Recall &
Reproduction

Limited

Knowledge
and Proficiency


2
Skills &
Concepts
Moderate
Knowledge

and Proficiency


3
Strategic
Thinking
4
Extended
Thinking
Advanced
Knowledge

and Proficiency


Superior
Knowledge

and Proficiency

A
Attitudes and
Motivation
Affective
Objective
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

Identifies basic facts and terms about the subject or competency.
Performs simple tasks associated with the competency. Needs
to be told or shown how to do most tasks.
Requires close supervision.
Identifies relationship of basic facts and states general principles
and can determine step-by-step procedures for doing the
competency.
Performs most parts of the competency. Needs help only on
hardest parts.
Requires limited supervision.
Analyzes facts and principles and draws conclusions about the
subject to include why and when the competency must be done
and why each step is needed. Can predict outcomes.
Performs all parts of the competency. Needs only a spot check
of completed work.
Requires little or no direct supervision.
Can evaluate conditions and make appropriate decisions as
related to resolving problems.
Performs competency quickly and accurately with no direct
supervision and is able to instruct and supervise others.
Describes learning objectives that emphasize a feeling tone, an
emotion, or a degree of acceptance or rejection.
Objectives vary from simple attention to selected phenomena to
complex but internally consistent qualities of character and
conscience.
Expressed as interests, attitudes, appreciations, values, and
emotional sets or biases.
27